1. Starter 20 questions
..\..\1 Defintions of Abnormality AQA\20 questions recap defintions.ppt

2. Learning outcomes: Consider problems with defining abnormal behaviour
to be able to describe and evaluate the reliability of the diagnosis of mental disorders
To be able to describe and evaluate the validity of the diagnosis of mental disorders
Describe the Rosenhan study in relation to the above issues

3. In order to diagnose and treat mental disorders, we need a system by which we can categorise them – put them in groups according to similarities (just as we do with physical illnesses).
A classification system is simply a comprehensive list of categories, including detailed descriptions of the symptoms characteristic of each.
The Diagnostic and Statistical Manual of Mental Disorder (Edition 5), was last published in 2013.
The DSM is produced by the American Psychiatric Association.
It is the most widely used diagnostic tool in psychiatric institutions around the world

4. ICD - 10
There is also the International Statistical Classification of Diseases (known as ICD).
It is produced by the World Health Organisation (WHO) and is currently in it’s 10th edition.

5. Reliability and the diagnosis of mental disorders
The DSM’s reliability rests on the question of
whether one person’s set of symptoms would lead to a common diagnosis by different physicians
If different doctors give different diagnosis for the same set of symptoms (e.g. for the same person), then the diagnosis are not reliable and the treatment may not work

6. Identification
Prognosis
Investigate causes
Treatment

7. Problems with defining abnormal behaviour
Ultimately we view MH as a medical issue….
Problems we might come across when trying to define abnormal behaviour…
Labelling: still a slight stigma attached to being labelled as mental ill. Do we think everyone in society understands? Is argued that it is easier to get a job after coming out of jail than out of a psychiatric hospital with a label of “mad””
Cultural differences: hearing voices in the west is seen as abnormal but in certain tribes, it is seen as a valuable and desirable as it is a link to the spirit world
Is it a moral decision rather than medical? Behaviours seen as morally unacceptable and therefore deemed “abnormal” – could be argued this is based on largely middle class, white educated section of society…e.g. homosexuality

8. Signs and symptoms: medical = signs such as cough, pain etc can be explored and symptoms such as high temp, blood pressure can be found. Signs confirm diagnosis. Mental health only usually symptoms and no signs
How can your mind me ill?!! Is there such a thing as mental illness? Or is it organic (physical only)
Where does the responsibility lie? If someone is mentally ill, are they therefore not responsible for their actions? E.g., people pled insanity to crimes so a lenient sentence is given.
What about murderers? Serial killers? Are they mentally ill? Should we label them ill as we find their behaviour difficult to comprehend?
However! Medical model does allow for treatment
Thomas Szasz: Interesting viewpoint…. No such thing as mental illness. Psychiatric hospitals act as “agents of social control” – on the surface try to help but unofficially trying to destroy them – One flew over the Cuckoos Nest

9. Classifications used in older versions of DSM now no longer considered abnormal
Homosexuality
Nymphomania (hunger for sex)
Drapetomania (caused slaves to run away)
We will just look at one of these – homosexuality (although it is useful to remember the other two in order to provide examples of changes in social norms that affect our ideas of what should be classified as a mental health problem).

10. Homosexuality
Homosexuality was declassified (removed) from DSM in Many psychiatrists fiercely opposed it being removed. In 1980, DSM-III included a condition known as ego-dystonic homosexuality, defined as:
a persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships, and
persistent distress from a sustained pattern of unwanted homosexual arousal.
The classification was removed entirely in 1986.
Ego dystonia refers to thoughts and behaviours (eg. dreams, impulses, compulsions, dreams etc.) that are in conflict with the needs and goals of the ego or in conflict with the person’s self-image.
It may be worth discussing why homosexuals may be more likely to suffer from ego dystonia (as defined in DSM III) in 1980 than they would now.

11. DSM-5 DSM-5 classifies mental disorders into major groups, including:
Depressive disorders
Anxiety disorders
Obsessive-compulsive and related disorders
Feeding and eating disorders
We will end by looking at how DSM-5 describes the three disorders you will be studying in detail as part of your Psychology course.
The following three slides are taken directly from the student book: useful to introduce the conditions before doing them in detail.

12. Phobias
A phobia is an irrational fear of an object or situation. DSM-5 distinguishes three groups of phobias:
Specific phobia: phobia of an object, such as an animal or body part, or a situation such as flying or having an injection.
Social anxiety (social phobia): phobia of a social situation such as public speaking or using a public toilet.
Agoraphobia: phobia of being outside or in a public place.

13. Depression
Depression is a mental disorder characterised by low mood and low energy levels. The categories of depression and depressive disorders in DSM-5 are:
Major depressive disorder: severe but often short- term depression.
Persistent depressive disorder: long-term or recurring depression, including sustained major depression and what used to be called dysthymia.
Disruptive mood dysregulation disorder: childhood temper tantrums.
Premenstrual dysphoric disorder: disruption to mood prior to and/or during menstruation.

14. Obsessive Compulsive Disorder – OCD
OCD is characterised by either obsessions (recurring thoughts, images, etc.) and/or compulsions (repetitive behaviours such as hand washing). Most people with a diagnosis of OCD have both obsessions and compulsions. Examples are:
Trichotillomania: compulsive hair pulling.
Hoarding disorder: the compulsive gathering of possessions and the inability to part with anything, regardless of its value.
Excoriation disorder: compulsive skin-picking.
Compulsive skin picking is a new addition to DSM.

16. * On being sane in insane places!
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D L Rosenhan (1973)
On being sane in insane places! *

17. * If sanity and insanity exist How shall we recognise them?
07/16/96
The Question…….
If sanity and insanity exist
How shall we recognise them? *

18. Does madness lie in the eye of the observer?*
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Specifically…….
1. Do the characteristics of abnormality reside in the patients or
2. In the environments in which they are observed?
Does madness lie in the eye of the observer? *

19. Recap of definitions of abnormality*
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Recap of definitions of abnormality
Abnormality IS
Behaviour which deviates from the norm
most people don’t behave that way
Behaviour which does not conform to social demands
most people don’t like that behaviour
Failure to Function Adequately
Deviation from Ideal Mental Health
Behaviour which is maladaptive or painful to the individual
its not normal to harm yourself
Statistical Infrequency *

20. What was Rosenhan’s interest?*
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What was Rosenhan’s interest?
How reliable are diagnoses of abnormality?
The astonishing study……….. On being sane in insane places…... D L Rosenhan (1973)
What did he do?
Who were involved? *

21. The brave volunteers……the pseudo patients*
07/16/96
The brave volunteers……the pseudo patients
EIGHT sane people!
one graduate student
three psychologists
a paediatrician
a painter
Housewife
Psychiatrist *

22. What did they DO? The procedure……………………..*
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What did they DO? The procedure……………………..
telephoned 12 psychiatric hospitals for urgent appointment (in five USA states)
arrived at admissions
gave false name and address
gave other ‘life’ details correctly *

23. complained of hearing unclear voices … saying “empty, hollow, thud”*
07/16/96
What else did they do?
complained of hearing unclear voices … saying “empty, hollow, thud”
Said the voice was unfamiliar, but was same sex as themselves
Simulated ‘existential crisis’
“Who am I, what’s it all for?” *

24. All were admitted to hospital*
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What happened? ………..
All were admitted to hospital
All but one were diagnosed as suffering from schizophrenia
Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms
Took part in ward activities *

25. What happened on the wards?*
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What happened on the wards?
The pseudo-patients were never detected
All pseudo-patients wished to be discharged immediately
BUT - they waited until they were diagnosed as ‘fit to be discharged’ *

26. How did the ward staff see them?*
07/16/96
How did the ward staff see them?
Normal behaviour was misinterpreted
Writing notes was described as -
“The patient engaged in writing behaviour”
Arriving early for lunch described as
“oral acquisitive syndrome”
Behaviour distorted to ‘fit in’ with theory (obsession with eating) *

27. The pseudo-patient’s observations…*
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The pseudo-patient’s observations…
If they approached staff with simple request
(NURSES & ATTENDANTS)
88% ignored them ~ (walked away with head averted)
10% made eye contact
2% stopped for a chat
(Total of 1283 attempts)
(PSYCHIATRISTS)
71% ignored them ~ (walked away with head averted)
23% made eye contact
2% stopped for a chat
(Total of 185 attempts) *

28. How long did they stay in hospital?*
07/16/96
How long did they stay in hospital?
The shortest stay was 7 days
The longest stay was 52 days
The average stay was 19 days
They had agreed to stay until they convinced the staff they were sane!! *

29. Were they treated in the same way as normal patients...*
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Were they treated in the same way as normal patients...
Given total of 2100 medication tablets
they flushed them down the loos
Noted that other patients did the same and that this was ignored as long as patients behaved themselves!! *

30. What sorts of records did they keep …….?*
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What sorts of records did they keep …….?
Nurses stayed in ward offices 90% of time
Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff *

31. Perhaps they behaved ‘abnormally’*
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Perhaps they behaved ‘abnormally’
Pseudo-patient’s visitors detected
“No serious behavioural consequences”
DID ANYONE SUSPECT?
NO!
35 out of 118 real patients voiced their suspicions *

32. Schizophrenia “IN REMISSION”*
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On release ………………...
The pseudo-patients were diagnosed as
Schizophrenia “IN REMISSION” *

33. Rosenhan The follow up study……………..*
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Rosenhan The follow up study……………..
A teaching & research hospital were told of the first study and warned that …
Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted *

34. What happened……….? 193 patients ‘assessed’*
07/16/96
What happened……….?
Staff members rated ‘new patients’ on scale as ‘how likely to be a fraud’
193 patients ‘assessed’
41 rated as a pseudo-patient (by staff)
23 rated as pseudo-patient (by psychiatrist)
19 rated as pseudo-patient (by both) *

35. How many of these SUSPECTS were pseudo-patients?……...*
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How many of these SUSPECTS were pseudo-patients?……...
NONE
No pseudo-patients were sent
Staff were rating their regular intake *

36. What did Rosenhan conclude?*
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What did Rosenhan conclude?
Remember .. His question was …
Do the characteristics of abnormality reside in the patients? or
In the environments in which they are observed?
Does madness lie in the eye of the observer *

37. Rosenhan’s conclusion…..*
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Rosenhan’s conclusion…..
“It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals”
In the first study - We are unable to detect ‘sanity’
In the follow up study - We are unable to detect ‘insanity’ *

38. Rosenhan’s study highlights! ...*
07/16/96
Rosenhan’s study highlights! ...
The depersonalisation and powerlessness of patients in psychiatric hospitals
That behaviour is interpreted according to expectations of staff and that these expectations are created by the labels
SANITY & INSANITY
The pseudo-patients described their stay in the hospitals as a negative experience
This is not to say that REAL patients have similar experiences
Real patients do not know the diagnosis is false & are NOT pretending
(Remember Zimbardo) *

39. Questions YOU should be able to answer...*
Relevance of the study today?
07/16/96
How do we accurately detect insanity?
Can we be confident in diagnosis?
Questions YOU should be able to answer...
Methodology of Rosenhan….
This was a participant observation, why?
Who were the OTHER participants?
Was this study ethical? If not why not?
Why might the reports of the pseudo-patients have been unreliable? *

40. HOMEWORK
For next lesson, please read the characteristics of phobias, depression and OCD.
Consolidate this week and ensure you have all 4 definitions of abnormality in your notes.

41. Additional info to help
* The DSM and diagnosis underpin the evaluation of explanations and therapies that we are going to look at. So, you will not be asked questions on the DSM specifically but it is expected that you refer to todays lesson when evaluating the disorders (OCD, Phobias and Depression)
Overview of DSM

42. Strengths Evaluation of the DSM
1. Allows for common diagnosis (although many revisions) because it has stood the test of time
When 2 or more doctors use the DSM, they should come close to the same diagnosis.
2. Evidence suggests that it is reliable ~Goldstein looked at the reliability between DSM-II and DSM-III is (1988)
She found there was evidence of reliability within the DSM-III (but less so between DSM-II and DSM-III)

43. Evaluation of the DSM
Weaknesses
The DSM is seen as a confirmation of the medical state of mental disorder, as suffers are ‘patients’ and ‘treatment’ is suggested.
Mental health issues are ‘disorders’ and ‘illnesses’ so ‘cures’ are looked for.
However, it might be said that some mental disorders are simply ways of living …. who is to say whether it is ‘illness’ or not. (e.g. schizophrenics may be trying to get back to their normal self)

44. ‘One Flew Over The Cuckoo’s Nest’ is the story of a criminal, Randle. P. McMurphy, who transfers himself into a psychiatric hospital from a hard labour camp in order to get what he thinks will be an easy ride. He rebels against the Nurse overlooking the hospital who has taken away any confidence the inmates had by being loud, destructive and by attempting to ruin any routine she has built. As time goes on the inmates all grow fond of him while the staff do just the opposite. However, the only way he can get out is for the Nurse to decide he is ready to go, but by now they think he may well be crazy.